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1248 www.ccmjournal.org July 2017 • Volume 45 • Number 7 amount of evidence (5–12) that ultrasound can be used to confirm CVC placement in a Critical Care setting. The authors used ultrasound to confirm correct placement of the CVC in the distal superior vena cava (SVC) or the SVC/ right atrial (RA) junction via 1) visualization of the guide wire in the distal SVC or SVC/RA junction, 2) direct visualization of the CVC tip in the distal SVC or SVC/RA junction, and 3) timing of appearance of agitated saline in the RA/right ventricle after injection into the CVC. They performed a subxiphoid four-chamber view or an apical four-chamber view to identify the wire in the RA after its advancement through the introducer needle. The CVC was then inserted over the guide wire and the tip visualized in the SVC or SVC/RA junction. The authors concluded that the CVC was in the correct position if the guide wire and/or CVC tips were seen on ultrasound in either the distal SVC or SVC/RA junction. It is important to note that “marked” wires were used in a prior study (5), which allowed exact measurement of how many centimeters of wire were inserted into the vessel and thus the distance to the RA/SVC junction. The authors also performed an agitated saline test as part of their protocol. This involved the injection of 10 cc of agitated saline into the newly placed catheter. If the saline immediately clouded the RA, then the CVC tip was likely located in the actual RA or inferior vena cava. If a jet of agitated saline was noted in the RA less than 2 seconds after injection, then the CVC tip was considered REFERENCES 1. Rhodes A, Evans LE, Alhazzani W, et al: Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock: 2016. Crit Care Med 2017; 45:486–552 2. Farris RW: Working toward “just right”: Fluid balance in pediatric septic shock. Crit Care Med 2014; 42:470–471 3. Long E, Duke T: Fluid resuscitation therapy for paediatric sepsis. J Paediatr Child Health 2016; 52:141–146 4. Bailey AG, McNaull PP, Jooste E, et al: Perioperative crystalloid and colloid fluid management in children: Where are we and how did we get here? Anesth Analg 2010; 110:375–390 5. Perel P, Roberts I, Ker K: Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev 2013; 2:CD000567 6. Marik P, Bellomo R: A rational approach to fluid therapy in sepsis. Br J Anaesth 2016; 116:339–349 7. Emrath ET, Fortenberry JD, Travers C, et al: Resuscitation With Balanced Fluids Is Associated With Improved Survival in Pediatric Severe Sepsis. Crit Care Med 2017; 45:1177–1183 8. Akech S, Ledermann H, Maitland K: Choice of fluids for resuscitation in children with severe infection and shock: Systematic review. BMJ 2010; 341:c4416 9. Ford N, Hargreaves S, Shanks L: Mortality after fluid bolus in children with shock due to sepsis or severe infection: A systematic review and meta-analysis. PLoS One 2012; 7:e43953 10. Avila AA, Kinberg EC, Sherwin NK, et al: The use of fluids in sepsis. Cureus 2016; 8:e528 11. Sinitsky L, Walls D, Nadel S, et al: Fluid overload at 48 hours is associated with respiratory morbidity but not mortality in a general PICU: Retrospective cohort study. Pediatr Crit Care Med 2015; 16:205–209 12. Ranieri VM, Rubenfeld GD, Thompson BT, et al: Acute respiratory distress syndrome: The Berlin definition. JAMA 2012; 307:2526–2533 13. Khemani RG, Smith LS, Zimmerman JJ, et al; Pediatric Acute Lung Injury Consensus Conference Group: Pediatric acute respiratory distress syndrome: Definition, incidence, and epidemiology: Proceedings from the Pediatric Acute Lung Injury Consensus Conference. Pediatric Crit Care Med 2015; 16:S23–S40 14. Gattinoni L, Cressoni M, Brazzi L: Fluids in ARDS: From onset through recovery. Curr Opin Crit Care 2014; 20:373–377 15. Byrne L, Van Haren F: Fluid resuscitation in human sepsis: Time to rewrite history? Ann Intensive Care 2017; 7:4 16. Myburgh JA: Fluid resuscitation in acute medicine: What is the current situation? J Intern Med 2015; 277:58–68 17. Ingelse SA, Wösten-van Asperen RM, Lemson J, et al: Pediatric acute respiratory distress syndrome: Fluid management in the PICU. Front Pediatr 2016; 4:21 18. Schramm GE, Kashyap R, Mullon JJ, et al: Septic shock: A multidisciplinary response team and weekly feedback to clinicians improve the process of care and mortality. Crit Care Med 2011; 39:252–258 19. Bell SK, Delbanco T, Anderson-Shaw L, et al: Accountability for medical error: Moving beyond blame to advocacy. Chest 2011; 140:519–526 20. Aveling EL, Parker M, Dixon-Woods M: What is the role of individual accountability in patient safety? A multi-site ethnographic study. Sociol Health Illn 2016; 38:216–232